Electroconvulsive Therapy-Resistant Catatonia: Case Report and Literature Review

Background: Untreated catatonia is associated with serious medical complications that can necessitate urgent medical attention. Lorazepam and electroconvulsive therapy (ECT) are effective for catatonia across various psychiatric or medical diagnoses. In rare cases, ECT fails to achieve full response in catatonic symptoms, particularly in patients with chronic catatonia or primary psychotic disorder. Evidence on treating catatonia that does not respond to ECT is lacking. Objective: Conduct a literature review on treatment of ECT-resistant catatonia which is defined as that reported lack of full response to ECT treatments. We present a case of a 52-year-old male with schizophrenia where catatonia did not respond to lorazepam and robust ECT but resolved after memantine titration. Methods: A literature review was performed using Medline/PubMed with the following keywords: treatment-resistant, catatonia, electroconvulsive therapy. References in eligible articles and most recent systematic reviews on catatonia treatment were reviewed. Results: Seventeen patients in 12 case reports were identified where the treatment of catatonia was described after failed ECT trials. Most had chronic catatonia and a diagnosis of schizophrenia. ECT parameters and ictal outcome measures were not consistently reported. Treatment modalities for ECT-resistant catatonia included amantadine, memantine, lorazepam augmentation to ECT, and antiepileptic and antipsychotic medications such as aripiprazole and clozapine. Conclusions: The literature review and new case suggest reconsideration of catatonia diagnosis, optimizing ECT treatments, cautious use of antipsychotics, consideration of lorazepam augmentation to ECT treatments, and/or use of N-methyl-D-aspartate receptor antagonists.